In addition to dealing with concerns about your medical condition, you need to know how to cover the costs of your transplant and medications, before and after your surgery. Finances are a major concern for patients and good planning will help to reduce this stress. Your transplant financial coordinator and social worker will help you address many of your financial issues and concerns. Together we can help you develop a plan to manage the financial impact of your illness, transplant surgery, and long-term recovery. We will ask you to take an active role in this process and may direct you to your current insurance provider and other resources in the community.
If You Have Insurance
If you have health insurance, ask your insurance company to explain its policy for transplant healthcare and to send you detailed information about your benefits in writing. Some possible questions include:
- Does BIDMC accept my type of health insurance to have a transplant? (Please note: Some insurance companies will allow you to be evaluated for a transplant at BIDMC but do not pay for a transplant at BIDMC.)
- Am I covered for a transplant right now? If there is a waiting period, how long must I wait?
- How much of the pre-transplant, transplant and post-transplant services does my insurance cover, and what specifically is covered?
- Are there out-of-pocket costs that I will be responsible for; if so what are they?
- Is there an annual cap on out-of-pocket costs?
- Are there any insurance company rules I need to follow to protect my benefits, such as pre-certification or using only certain providers?
- Is there a "cap" (or maximum lifetime limit) on the amount of health insurance coverage and/or medication coverage that I have?
- Do I need a second opinion, and if so, who will pay for it?
- If I want a second opinion, will my insurance pay for it?
- Will I be covered for skilled nursing or rehabilitation care before or after my transplant?
If your health plan covers only some of the costs, our financial coordinator and social worker can help you find ways to finance the out-of-pocket expenses. If you have stopped working because of your illness, they can also help you determine if, and how, you can extend your former coverage.
If You Do Not Have Insurance
Having a transplant can be very expensive over the long-term. Therefore, having health insurance and prescription drug coverage in place is important. There are several options for patients who do not have any type of health insurance.
Our transplant financial coordinator and social worker can help you explore funding options if you do not have insurance. A few possible options for you to discuss with our financial coordinator and social worker include:
- Do I qualify for
Medicaid, the health insurance program that covers certain patients without insurance?
- Do I qualify for
Commonwealth Care, the new state insurance program for uninsured Massachusetts' residents?
- Does my spouse/partner have insurance that I might be able to enroll in?
- Can I afford to pay privately for an individual insurance plan?
- Are there any local fundraising organizations that can help me?
- Should I start my own fundraising effort and if so, how?
You may wish to visit the National Foundation for Transplants,
www.transplants.org, or the National Transplant Assistance Fund,
www.transplantfund.org. Both of these organizations help patients and families with fundraising for transplant-related expenses. Also, the Anthony Picarello Foundation,
www.ap-foundation.org, helps people with transplant-related expenses.
Medicaid is the health coverage program for certain low and medium income residents. Individual states decide who qualifies for Medicaid and what services and benefits are covered. Your transplant financial coordinator or social worker can refer you to your local Medicaid office to determine if you are eligible for benefits. Eligibility is based on both household income and level of physical/emotional disability. For more information, contact the Medicaid office in your home state:
Some patients may be eligible for Medicare. Federal tax money funds this health insurance program, which is administered by the Centers for Medicare and Medicaid Services. Medicare is open to citizens or permanent residents of the United States who are:
- 65 years or older, or
- disabled, or
- who have permanent end-stage renal disease
For more information about Medicare-covered services, call the Centers for Medicare and Medicaid Services, toll free at 877-267-2323 or visit
www.medicare.gov. You can also speak with our transplant financial coordinator.
Insurance Coverage after a Transplant
After you can return to work, you will want to take a close look at your employer's health insurance options. Your company may have a yearly open-enrollment period, which may mean a change in your health plan. If you must change your health plan, you should ask if transplantation is covered, if there is a lifetime maximum on transplant coverage and medication coverage, and if there is a pre-existing condition waiting period. Be sure to keep your financial coordinator updated on any changes in your insurance to ensure a smooth transition in your transplant care. Our financial coordinator or social worker can help you organize your questions for your employer regarding your health insurance options.
Costs for Some Common Medications
The following are out-of-pocket expenses for a one-month supply of six of the more common post-transplant drugs, without any insurance coverage:
Prograf® - $1170
Cellcept® - $422
Valcyte® - $2324
Norvasc® - $32
Nystatin - $107
Bactrim® - $12
A Financial Plan
Developing a financial plan is a critical part of preparing for a transplant. We expect you to work with the social worker and financial coordinator at the Transplant Center, and with the case manager at your insurance company, in an effort to minimize the financial impact of a transplant.